Cancer-related microangiopathic hemolytic anemia (MAHA) is a rare and life-threatening condition. We present a patient who had been treated for invasive lobular breast carcinoma in clinical remission with fever and hemolytic anemia. The peripheral blood film showed MAHA and thrombocytopenia, and a functional deficiency of ADAMTS13 activity of 23% consistent with acquired thrombotic thrombocytopenic purpura. Bone marrow aspirate and trephine biopsy confirmed metastatic carcinoma. Further evaluation revealed the involvement of multiple bone sites without recurrence of the primary tumor. The patient received a daily plasma exchange with cryosupernatant and was pulsed with corticosteroids. MAHA related to breast cancer appears to be a rare occurrence.

1. Laszik, Z. G., & Silva, F. G. (2007). Hemolytic-uremic syndrome, thrombotic thrombocytopenic purpura, and other thrombotic microangiopathies and coagulopathies. In J. C. Jennette, J. L. Olson, M. M. Schwartz, & F. G. Silva (Eds.), Heptinstall's Pathology of the Kidney (6th ed., pp. 699–762). Lippincott Williams & Wilkins.
2. Moschcowitz, E. (1925). An acute febrile pleiochromic anemia with hyaline thrombosis of the terminal arterioles and capillaries: An undescribed disease. Archives of Internal Medicine, 36(1), 89–93. https://doi.org/10.1001/archinte.1925.00120130092009
3. Levy, G. G., Nichols, W. C., Lian, E. C., Foroud, T., McClintick, J. N., McGee, B. M., Yang, A. Y., Siemens, D. R., Stark, K. R., Gruppo, R., Sarode, R., Shurin, S. B., Chandrasekaran, V., Stabler, S. P., Sabio, H., Bouhassira, E. E., Cromwell, C. C., Yin, J. L., Bodensteiner, D. C., ... Ginsburg, D. (2001). Mutations in a member of the ADAMTS gene family cause thrombotic thrombocytopenic purpura. Nature, 413(6855), 488–494. https://doi.org/10.1038/35097008
4. Moake, J. L. (2002). Thrombotic microangiopathies. New Journal of Medicine, 347(8), 589–600. https://doi.org/10.1056/nejmra020528
5. Reese, J. A., Muthurajah, D. S., Hovinga, J. A. K., Vesely, S. K., Terrell, D. R., & George, J. N. (2013). Children and adults with thrombotic thrombocytopenic purpura associated with severe, acquired ADAMTS13 deficiency: Comparison of incidence, demographic and clinical features. Pediatric Blood & Cancer, 60(10), 1676–1682. https://doi.org/10.1002/pbc.24612
6. Antman, K. H., Skarin, A. T., Mayer, R. J., Hargreaves, H. K., & Canellos, G. P. (1979). Microangiopathic hemolytic anemia and cancer: A review. Medicine, 58(5), 377–384. https://doi.org/10.1097/00005792-197909000-00004
7. Oberic, L., Buffet, M., Schwarzinger, M., Veyradier, A., Clabault, K., Malot, S., Gilbert, T., Boffa, J. J., Schleinitz, N., Vanhille, P., Ryckelynck, J. P., Rigouzzo, A., de Prost, A. C., Galicier, L., & Azoulay, E. (2009). Cancer awareness in atypical thrombotic microangiopathies. The Oncologist, 14(8), 769–779. https://doi.org/10.1634/theoncologist.2008-0272
8. Zwicker, J. I., Liebman, H. A., Neuberg, D., Lacroix, R., Bauer, K. A., Furie, B. C., & Furie, B. (2009). Tumor-derived tissue factor–bearing microparticles are associated with venous thromboembolic events in malignancy. Clinical Cancer Research, 15(22), 6830–6840. https://doi.org/10.1158/1078-0432.CCR-09-0371
9. Lechner, K., & Obermeier, H. L. (2012). Cancer-related microangiopathic hemolytic anemia: Clinical and laboratory features in 168 reported cases. Medicine, 91(4), 195–205. https://doi.org/10.1097/MD.0b013e3182603598
10. Rieger, M., Mannucci, P. M., Hovinga, J. A. K., Herzog, A., Gerstenbauer, G., Konetschny, C., Bodemer, C., Besalduch, J., Osterwalder, B., Lämmle, B., & Scheiflinger, F. (2005). ADAMTS13 autoantibodies in patients with thrombotic microangiopathies and other immunomediated diseases. Blood, 106(4), 1262–1267. https://doi.org/10.1182/blood-2004-11-4481
11. van der Plas, R. M., Schiphorst, M. E., Huizinga, E. G., Hené, R. J., Verdonck, L. F., Sixma, J. J., & Furlan, M. (1999). von Willebrand factor proteolysis is deficient in classic, but not in bone marrow transplantation–associated, thrombotic thrombocytopenic purpura. Blood, 93(11), 3798–3802. https://doi.org/10.1182/blood.V93.11.3798
12. Alhenc-Gelas, M., Cabel, L., Berger, F., Delaloge, S., Frenel, J. S., Levy, C., Pierga, J. Y., & Coppo, P. (2021). Characteristics and outcome of breast cancer-related microangiopathic haemolytic anaemia: A multicentre study. Breast Cancer Research, 23(1), 1–10. https://doi.org/10.1186/s13058-021-01438-x
13. Schrader, K. A., Masciari, S., Boyd, N., Wiyrick, S., Kaurah, P., Senz, J., Saunders, M. C., Yorida, E., de Jong, G., Huntsman, D. G., & Garber, J. E. (2008). Hereditary diffuse gastric cancer: Association with lobular breast cancer. Familial Cancer, 7(1), 73–82. https://doi.org/10.1007/s10689-007-9154-0
14. Wahrenbrock, M., Borsig, L., Le, D., Varki, N., & Varki, A. (2003). Selectin-mucin interactions as a probable molecular explanation for the association of Trousseau syndrome with mucinous adenocarcinomas. Journal of Clinical Investigation, 112(6), 853–862. https://doi.org/10.1172/JCI18882
15. Amorosi, E. L., & Ultmann, J. E. (1966). Thrombotic thrombocytopenic purpura: Report of 16 cases and review of the literature. Medicine, 45(2), 139–160. https://doi.org/10.1097/00005792-196603000-00003